3-point Fixation Research Articles

The “Bony Bankart Bridge” Procedure: A New Arthroscopic Technique for Reduction and Internal Fixation of a Bony Bankart Lesion

Arthroscopic treatment of bony Bankart lesions can be challenging. We present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule. We call this the “bony Bankart bridge” procedure.

A biomechanical comparison of repair techniques in posterior type II superior labral anterior and posterior (SLAP) lesions

The purpose of this study was to compare the 3 different fixation methods of posterior type superior labral anterior posterior (SLAP) II lesion. Fifteen cadavers were randomly divided into 3 groups to compare the initial strength of 3 different fixation methods in posterior type II SLAP lesions. Group I used 1 anchor for 1-point fixation with a conventional simple suture; group II used 1 anchor passing both limbs through the posterior-superior labrum in a mattress fashion; and group III used 2 anchors for 2-point fixation with conventional simple sutures. Repair failure (2 mm permanent displacement of repaired site) and ultimate failure were measured. The mean load to (clinical) failure was 156 +/- 22 N in group I, 117 +/- 33 N in group II, and 161 +/- 44 N in group III. The mean load to ultimate failure was 198 +/- 6 N in group I, 189 +/- 23 N in group II, and 179 +/- 22 N in group III. The specimen stiffness was equivalent among groups. In mode of failure, clinical failure (more than 2 mm separations) first occurred between the markers on the biceps tendon just above (A) and below (B) compared to other markers, and ultimate failure occurred at the labral-implant interface. A single simple suture anchor repair in posterior type II SLAP seems sufficient to withstand the initial load without clinical failure. A mattress suture, although it anchors the biceps root, seems to be inferior than simple suture technique.

Frameless Stereotactic Treatment of Brain Metastases Using Cone-Beam CT Based Image Guidance

The high precision necessary for single fraction high dose brain treatments is usually attained by the employment of invasive stereotactic frames. However, standard mask fixation used for fractionated brain and head-and-neck treatments does have the potential to provide very good short-term stability. The overall geometrical accuracy will then be limited by the ability to localize the patient on the Linac. We developed a procedure that applies on-line set-up corrections based on bony anatomy registration of cone-beam computed tomography (CBCT) data acquired on the treatment machine, which enables a non-invasive treatment for this patient group. The aim of this study is to determine the accuracy of this approach. Twenty patients were included in the protocol thus far. Standard PETG masks with 3-point fixation were used. Prior to treatment a CBCT scan (Elekta Synergy 3.5) was acquired and matched to the planning CT scan. Deviations larger than 1 mm were corrected by a manual couch shift. Corrections were validated with a second CBCT scan. To assess intra-fraction errors a third scan was acquired after treatment. All scans were registered with in-house developed software that uses a 6-D rigid body transform (3 translations and 3 rotations). The rotation center of the registration was placed in the middle of the PTV to minimize the effect of rotations. The pre-and post-treatment setup errors were computed in terms of a group standard deviation (SD) and overall mean. Matching accuracy was estimated by comparing the registrations of any pair of scans in a “full circle”. Finally, intra-fraction motion was quantified by the difference between the pre- and post-treatment measurements. Sixteen patients were corrected in either one or more directions. The mean and standard deviation of the corrected set-up errors were smaller than 0.1 mm and 1 mm respectively. Intra-fraction motion was smaller than 0.5 mm (SD) in any direction with no significant mean differences (Table). The matching accuracy, as derived from the “full circle” analysis was slightly smaller than the intra-fraction movement. The proposed method is accurate and comparable to methods utilizing an invasive stereotactic frame. The intra-fraction movement was very small, which shows that the rigidity of the PETG mask is sufficient for this type of treatment. Furthermore, registration accuracy is not limiting the total precision of the procedure. In conclusion, the use of CBCT on a linear accelerator to determine and correct set-up errors in combination with standard mask fixation does provide the accuracy needed for frameless stereotactic treatments.Tabled 1Left-right (mm)Cranial-caudal (mm)Anterior-posterior (mm)MeanSDMeanSDMeanSDBefore corr.−0.51.10.82.2−0.41.5After corr.−0.10.50.10.80.10.5Intra frac.0.10.60.20.4−0.10.5 Open table in a new tab

Analysis of outcomes of single polypropylene mesh in total pelvic floor reconstruction

A 2.5-year outcome analysis was performed on patients who underwent transvaginal repair of total pelvic organ prolapse with single polypropylene mesh. A description of the repair technique using a tension-free 4-point fixation is also reviewed. After proper vaginal dissection, a specially fashioned "H" shaped polypropylene mesh is positioned and fixed at 4-points. With a single piece of mesh, the anterior arms provide mid-urethral and bladder neck support, the mid-portion of the mesh corrects anterior compartment defects, and the posterior arms aid in vaginal vault suspension. Initially, bone anchors were utilized for anterior fixation, but currently a tension-free method is used. A retrospective analysis using chart review was performed on 96 patients who underwent this procedure from January 2000 to June 2005. Additional information was gathered by a telephone survey using a questionnaire. Statistical analysis was performed using Student's t-test, with Sigma Stat(R). Seventy-six patients (79%) were available with a mean follow-up time of 30.7 +/- 1.7 months and mean age of 69.3 +/- 11.3. Among those with follow-up, 36 patients (47.4%) underwent concurrent hysterectomies. Recurrence of prolapse was reported by four patients (5.2%). Sixty-eight patients (89%) were completely dry or almost dry, defined as an occasional leak. For those with preoperative incontinence (n = 36), average pad use per day decreased significantly from 2.1 +/- 0.4 to 0.8 +/- 0.2 (P < 0.005) postoperatively. Twelve patients (15.7%) reported of de novo urgency. Six patients required reoperation including excision of vaginal mesh erosion (2), uretholysis for obstruction (1), removal of palpable vaginal suture (1), and recurrent SUI (2). Among the 21 patients who are sexually active, 19 denied any dyspareunia (90.4%). Patient satisfaction was high, as the mean value was 7.9 +/- 0.3 on a scale of 1 (least satisfied) to 10 (most satisfied). Transvaginal repair of complete pelvic prolapse using polypropylene mesh is a safe and efficacious option, with minimal recurrence of prolapse and SUI. While two patients had vaginal erosions, no urethral or bladder erosions occurred. Patient satisfaction was overall favorable.

Management of posteriorly dislocated endocapsular tension ring and intraocular lens complex

We report a case of late posteriorly dislocated endocapsular tension ring (ECR) and intraocular lens (IOL) complex into the vitreous cavity that behaved as a single 13 mm disc. A 3-port pars plana vitrectomy was performed, and perfluorocarbon liquid was used to retrieve the ECR-IOL complex to the retropupillary area. A 3-point scleral fixation was performed to reposition the inseparable ECR-IOL complex.

Surgical Repositioning of Dislocated Capsular Tension Rings

To present techniques and results of surgical repositioning of subluxed and dislocated capsular tension rings (CTRs). Retrospective interventional case series. Eleven patients with a previously implanted CTR in-the-bag for zonular weakness who presented with CTR-intraocular lens (IOL)-capsular bag decentration who underwent surgical repositioning. Data from 11 patients who underwent surgical repositioning were evaluated retrospectively for underlying diagnosis, interval between initial surgery and decentration, surgical technique, clinical results, and complications. Capsular tension ring-IOL-capsular bag centration, final best-corrected visual acuity (BCVA), and surgical complications. Of the 11 patients with CTR decentration, 3 had it early in the postoperative period, and 8 had it late. Mean (+/- standard deviation) durations from cataract extraction and CTR implantation to surgical repositioning were 6.1+/-7.9 months for those with decentration early and 49.6+/-15.3 months for late decentrations (overall range, 0.7-74.7). Of the 11 patients, 7 had pseudoexfoliation, and 4 of the 7 had associated glaucoma. Nine patients had subluxation of the CTR-IOL-capsular bag complex, which was managed by an anterior segment approach. A pars plana vitrectomy and levitation of the CTR was required in 2 patients due to complete dislocation of the CTR into the posterior vitreous. Surgical techniques for repositioning included single, double, or 3-point scleral suture loop fixation of the CTR through the capsular bag complex (8 eyes); use of the capsular tension segment (CTS) placed within the capsular bag for scleral suture fixation (2); or iris suture fixation of the IOL haptics (1). All patients achieved successful anatomical repositioning of the CTR-IOL-capsular bag complex. Mean preoperative BCVA improved from 20/100 to 20/40 postoperatively. After repositioning surgery, BCVA improved in 7 patients, was maintained in 2, and worsened in 2 (due to advanced glaucoma). Postoperative CTR subluxation or dislocation is a risk for patients with severe or progressive zonulopathy. Decentrations may be effectively managed with scleral suture fixation of the CTR through the capsular bag or the use of the CTS.

Prevention of Suture Knot Exposure in Posterior Chamber Intraocular Lens Implantation by 4-Point Scleral Fixation Technique

The results and complications of posterior chamber intraocular lens (IOL) implantation by a 4-point scleral fixation technique are described. Fifty eyes of 47 patients who underwent scleral-fixated IOL implantation were retrospectively evaluated. Twenty-one (42%) eyes had a history of trauma and 29 (58%) eyes had previously undergone cataract surgery. In all cases, IOL implantation by 4-point scleral fixation was performed and the knots of fixation sutures were rotated and buried in the globe. The IOL position was adjusted by suture rotation for best centration. The mean follow-up time was 7 +/- 4 months. Four (8%) eyes had minimal corneal edema preoperatively. Cystoid macular edema was noted in 2 (6.8%) eyes in the cataract surgery group and 8 (38%) eyes in the posttraumatic group. Two (9.5%) eyes in the posttraumatic group had atrophic macular changes and 1 (4.7%) had corneal scarring, which impaired vision. No complications such as knot exposure, tilting of the IOL, decentralization, or endophthalmitis were noted postoperatively. Postoperative mean corrected visual acuity was 0.4 +/- 0.3 in the posttraumatic group and 0.4 +/- 0.2 in the cataract surgery group. The 4-point scleral fixation technique resulted in no serious postoperative complications such as suture exposure and endophthalmitis. Because the knot can be rotated and buried in the globe, knot exposure is less likely to occur. This procedure is more effective than other techniques regarding IOL centralization.

Suture fixation technique for posterior chamber intraocular lenses

We describe a modified method for scleral fixation of posterior chamber intraocular lenses (IOLs). A double-armed, 10-0 polypropylene (Prolene®) suture on a curved long needle is passed through a groove in the sclera and retrieved within the barrel of a bent 25-gauge needle through the opposite groove. Double transscleral passages enable 4-point fixation and provide better stability and centration. Knots are buried completely in the scleral groove. In a series of 10 cases, the IOLs were well centered, no sutures protruded from the scleral groove, and the vision in all eyes improved. In 1 case, a ciliary hemorrhage occurred during insertion of the 25-gauge needle, but the bleeding stopped after ocular pressure reform. This technique is easy to perform, improves centration and stability of the IOL, and avoids suture exposure.

A quantitative analysis of bone support comparing cementless tapered and distal fixation total hip replacements

The purpose of this study was to develop a technique to accurately assess cementless femoral stem-bone contact. Using this technique, differences in contact patterns between tapered (Synergy) and cylindrical distal fixation (Prodigy) cementless stems were explored. Femurs were prepared and the 2 types of femoral stems were implanted. After implantation, the femurs were imaged in a spiral computed tomography scanner and analyzed using novel custom-developed imaging software. This analysis used a geometric deformable-model UNIX-based software that determined bone-prosthesis contact area. The tapered stem features proximal, cancellous bone contact and a 3-point fixation pattern. The cylindrical distal fixation stem demonstrates cortical support in the distal aspect of the stem.

A comparative study on the use of photoreagents for the enhancement of adhesion on heavy-duty leather (Salz leather)

This paper aims to expand on work presented by us in previous publications regarding the enhancement of adhesion on leather substrates with photoreagent type primers. Two new reagents were synthesized: 3,5-dihydroxyphenyl-4-azidobenzoate ( 7) and 4,4′-ethylene-1,1′-diphenyl azide ( 8) and used as an intimate mixture with commercial polyurethane adhesive (Solibond PU39), to enhance the adhesion of Salz leather surfaces. The molecular design of the primer molecule was intended to provide 2- and 3-point fixation between the substrate and adhesive. The strength of adhesive joint s do not seem to be highly dependent on the molecular structure of the primer s investigated in respect to the type of OH groups present (aliphatic or aromatic), both confer high adhesive strengths under dry and wet testing conditions. Cyanuric chloride (CNCl) 3 a commercially used primer when tested under the same conditions for comparison purposes, gave good results but with a high standard deviation. Overall, the azide primers generate good, reliable joint strengths under extreme testing conditions and we believe they present negligible technological problems to industrial scale implementation.

Short-Term Outcome Analysis of Total Pelvic Reconstruction With Mesh:: The Vaginal Approach

We describe our experience with transvaginal total pelvic reconstruction using a mesh with 4-point fixation for patients with genitourinary prolapse with or without stress urinary incontinence. A total of 29 consecutive patients who underwent sacrospinous fixation using mesh material since March 1999 for genitourinary prolapse were analyzed retrospectively. In all patients defect specific repair was done, including hysterectomy (in 13). For isolated vault prolapse a rectangular mesh was interposed between the peritoneum and vaginal vault, with each corner anchored to the sacrospinous ligament using a suture-capturing device. For vault prolapse associated with anterior vaginal wall prolapse an "H" shaped, 1-piece sling was used to support both entities. Additionally, posterior and perineal repairs were done through separate incisions if needed. Of the 29 patients 19 (65.5%), 7 (26.92%) and 11 (39.29%) had associated symptoms of stress urinary incontinence, urgency and frequency, respectively, and 79.31% had associated anterior and 44.8% had associated posterior prolapse. Average operative time was 175.6 minutes, blood loss was 340 cc and hospital stay was 2.46 days. Early adverse events following the procedure were perineal pain, vaginal discharge and irritative voiding symptoms. At 6 month followup (mean 25.14 months) mild constipation and dyspareunia were encountered in a small subset of patients. Two patients (6.89%) have genital prolapse recurrence and none has reported erosion or nonhealing to date. Transvaginal technique of 4-point vaginal vault fixation using mesh is a safe and effective procedure at 2 years.

Four-point fixation of posterior chamber intraocular lenses in children with unilateral aphakia

Purpose To evaluate the results of 4-point scleral fixation of posterior chamber intraocular lenses (PC IOLs) in children. Setting Mansoura Ophthalmic Center, Mansoura University, Mansoura, Egypt. Methods This retrospective study comprised 20 aphakic eyes of 20 children. Preoperative investigations proved the absence of adequate posterior capsule support. All patients had ab externo 4-point scleral fixation of a PC IOL. All preoperative and postoperative data were studied and analyzed. Results The mean preoperative age was 7.7 years (range 4 to 11 years). The mean follow-up was 19.35 months (range 13 to 30 months). The preoperative findings included a best corrected visual acuity of 6/18 or better in 8 eyes (40%), corneal scarring in 18 eyes, sector iridectomy in 7 eyes, and after-cataract in 4 eyes. The intraoperative complications included vitreous hemorrhage in 2 eyes and slippage of 1 suture in 1 eye. Postoperative complications included mild anterior uveitis in 12 eyes and severe fibrinoid reaction in the anterior chamber in 8 eyes. There were no cases of suture exposure, IOL malpositioning, or infection. Twelve patients (60%) had a visual acuity of 6/18 or better. The cause of the poor visual outcome in many patients was preexisting amblyopia. Conclusions The results suggest that 4-point scleral fixation is an option to correct aphakia in children. However, long-term follow-up is important to assess the procedure’s safety.

Management of Pediatric Femoral Fractures using K-Wires

Management of Pediatric Femoral Fractures using K-Wires

A simple technique for preventing bar displacement with the nuss repair of pectus excavatum

Background/Purpose: The most common complication of the minimally invasive technique for repair of pectus excavatum (MIRPE) is bar displacement, which has been reported to occur in 9.5% of all cases, particularly in teenaged patients. The use of a lateral stabilizing bar has improved stability but has not eliminated the occurrence of this problem. The authors report a new technique added to the standard MIRPE that creates an additional third point of fixation of the pectus bar to prevent displacement. Methods: The technique requires the simple placement, via a spinal needle, of a nonabsorbable suture next to the sternum, encircling a rib and the bar, using a single 3-mm stab wound and thoracoscopic guidance. The suture simply is buried under the skin. Since 1998, this technique has been applied to 20 patients who underwent MIRPE. Results: The average age was 14 years; 80% were boys. Average operating time was 75 minutes, and all patients had thoracoscopy with the MIRPE. A lateral stabilizing bar also was used in 14 patients. Four patients had 2 struts placed. Average length of stay was 5.5 days. There were no early complications. Mean follow-up was 12 months. Bar displacement occurred in 1 patient early in the series in which an absorbable suture was used for fixation. One patient had a prolonged hospital stay of 7 days because of postoperative pain. Conclusions: This modification to the original technique of MIRPE creates a 3-point fixation system that minimizes the risk of bar shifting even in teenaged patients. It does not add any significant time or cost to the operation, and it is fairly simple to perform. The authors believe that this technique decreases the occurrence of bar displacement, and they recommend its use for all patients with pectus excavatum considered candidates for the Nuss repair. J Pediatr Surg 36:1266-1268. Copyright © 2001 by W.B. Saunders Company.

Biomicroscopia ultra-sônica na avaliação da posição das lentes intra-oculares em uma técnica de fixação escleral

Objetivo: Avaliar pela biomicrospia ultra-sônica (UBM) o posicionamento, em relação ao sulco ciliar, das alças de lentes intra-oculares (LIO), em uma técnica de fixação escleral, avaliando-se também se dois pontos de fixação são suficientes para que não haja inclinação da parte óptica. Métodos: Dezesseis olhos afácicos foram submetidos a implante LIO por uma mesma técnica de fixação escleral, realizados por um mesmo cirurgião. Um mês após a cirurgia, o posicionamento das alças das LIO foram avaliados pelo UBM, assim como distâncias entre as LIO e córnea. Os resultados foram submetidos a testes estatísticos. Resultados: Das 32 alças fixadas à esclera, oito estavam localizadas no sulco ciliar e 24 fora deste. Não houve diferença estatística nas distâncias entre LIO e córnea para alças posicionadas no sulco ciliar quando comparadas àquelas localizadas fora do sulco. Isto sugere que, além da distância ao limbo que se transfixa a esclera, outros fatores devem estar associados ao posicionamento da alça no sulco ciliar. As medidas LIO -- córnea realizadas na periferia das LIO às 3, 6, 9, e 12 horas foram semelhantes, mostrando que dois pontos de fixação são suficientes para que a LIO não fique inclinada. Conclusões: Outros fatores (por exemplo o ângulo de abertura do corpo ciliar), além da distância ao limbo na qual se transfixa a esclera, são importantes para o posicionamento das alças no sulco ciliar. Dois pontos de fixação são suficientes para que a LIO não apresente inclinação dentro do olho.

Repair of zygomaticomalar complex fractures. The Swiss method.

The zygomaticomalar complex fracture, also known as the trimalar, tripod, or tetrapod fracture, is a fracture commonly encountered by facial plastic surgeons. Failure to correctly reduce these fractures can lead to facial asymmetry, trismus, diplopia, enophthalmos, and parasthesias. Approaches to the zygomaticomalar complex have been well documented in the literature and include the transconjunctival lateral canthotomy, subciliary blepharoplasty, brow, gingivobuccal, and coronal incisions, or some combination thereof. Fracture fixation is accomplished by the internal placement of miniplates and microplates across properly reduced fracture lines to resist torsional rotation and masticatory distraction. The method of fracture reduction and fixation employed at the University Hospital of Bern, Switzerland, shares much with previously published and accepted methods of medial and lateral buttress reconstruction, but it introduces several original concepts in an attempt to maximize functional and aesthetic outcomes.

Long-term follow-up of primary anterior chamber intraocular lens implantation

Purpose: To evaluate the long-term outcome in eyes having primary anterior chamber intraocular lens (AC IOL) implantation.Setting: Kimura Eye and Internal Medicine Hospital, Hiroshima, Japan.Methods: Primary AC IOL implantation was performed in 171 eyes from 1983 to 1988. Two lenses were implanted: the open C-loop Simcoe lens and the 4-point fixation Kelman lens. In 86 eyes that had a mean follow-up of 9 years 7 months, visual acuity, corneal endothelial cell density, pupil shape, and the presence of associated complications were examined.Results: Although the final visual acuity was 0.5 or better in 60 eyes (69%), corneal endothelial cell density was less than 2000 cells/mm2 in 46 eyes (57%). Postoperative complications included a deformed pupil in 48 eyes (56%) and bullous keratopathy in 12 eyes (14%). In 14 eyes the AC IOL was explanted; 11 of these were the open C-loop Simcoe lens.Conclusion: Although our findings show that the open C-loop AC IOL (Simcoe) is contraindicated, implantation of the 4-point fixation AC IOL may be acceptable in selected cases.

The 2-point fixation using mini-plates and screws in the treatment of tripod fractures of the zygoma

The 2-point fixation using mini-plates and screws in the treatment of tripod fractures of the zygoma

Functional bracing of fractures of the second through fifth metacarpals

A simple new brace aids in the reduction and immobilization of fractures of the second, third, fourth, and fifth metacarpals. This brace incorporates an adjustable strap and pads made of radiolucent materials. It provides 3-point fixation while allowing full range of motion of the wrist and digits. It has been preferred by patients to an ulnar gutter splint, and its use resulted in less residual angulation of the fracture than occurred with other methods.